Provider Demographics
NPI:1508225624
Name:TRILOGY HEALTHCARE OF OAKLAND II, LLC
Entity Type:Organization
Organization Name:TRILOGY HEALTHCARE OF OAKLAND II, LLC
Other - Org Name:NOVI LAKES HEALTH CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-412-5847
Mailing Address - Street 1:PO BOX 221648
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40252-1648
Mailing Address - Country:US
Mailing Address - Phone:502-412-5847
Mailing Address - Fax:
Practice Address - Street 1:41795 W 12 MILE ROAD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377
Practice Address - Country:US
Practice Address - Phone:248-449-1655
Practice Address - Fax:248-449-1637
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRILOGY OPCO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-17
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1508225624Medicaid
MI1508225624Medicaid